Healthcare Provider Details

I. General information

NPI: 1720350895
Provider Name (Legal Business Name): BALANCED BODY-ORTHOPEDIC PHYSICAL THERAPY & FITNESS TRAINING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 W MEMORIAL RD SUITE 310
OKLAHOMA CITY OK
73134-1512
US

IV. Provider business mailing address

3705 W MEMORIAL RD SUITE 310
OKLAHOMA CITY OK
73134-1512
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-6281
  • Fax: 405-936-6496
Mailing address:
  • Phone: 405-749-6281
  • Fax: 405-936-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateOK

VIII. Authorized Official

Name: KEVIN BLAYLOCK
Title or Position: CFO
Credential:
Phone: 405-749-6281